The U.S. and
Portugal have significant differences in their healthcare systems. The United States spends 15.2% of the GDP on
healthcare and spending is divided into several subcategories: Managed care
(primarily funded by employers), Military (TRICARE and VA facilities), and
Vulnerable Populations (poor, elderly, disabled, children, etc.). There is no
central governing agency in the U.S. healthcare system, providing for little
integration and coordination between entities within the system. The healthcare provided to the U.S.
population is primary technology-driven and focuses on acute care, which fuels
research and innovative new medical technology and growth; at the same time
however, a new demand is then created for certain innovative services and
equipment, despite shrinking resources.
This, together with a lack of central regulatory efforts, provides for medical
care that is average in outcomes, unequal in its distribution, and high in
cost. Additionally, healthcare costs are
paid for both publicly and privately, with most of healthcare spending (>50%)
funded through the private sector (private insurance, prepaid plans, etc.) and
it is one of the few countries in the world that does not guarantee access to
health care for its population, leading to an uninsured rate of over 16% in
2010. The U.S. system, in an effort
uphold the Founding Fathers’ ideas of limiting the government’s role in big
business and providing for a free market has created a limited access system,
whereby medical care is restricted to those that have health insurance through
a private or government employer, are considered a vulnerable population and
are covered under a government program, can afford to purchase private
insurance out-of-pocket, or are able to pay for care on a fee-for-service basis
privately.
The
Portuguese Healthcare system is very different than the U.S. system. Portugal has a centralized healthcare system
referred to as the National Health Insurance system (NHI), where most of
healthcare spending is provided for and regulated by the government and the
population is guaranteed access to care.
This system was provided for by the social security administration in
the 1970s. The National Healthcare
Insurance system essentially provides universal coverage and is funded through the
general taxation of employers and employees in addition to direct payments by
patients and voluntary health insurance premiums. Short-term European Union visitors are also
able to access this system. Benefits
include general and specialist care, hospitalizations, lab services,
pharmaceuticals, basic dental care, maternity care, transportation, medical
equipment/supplies; however, it is limited in its coverage for outpatient
treatment, geriatric assistance, terminal illness services, and psychiatric
treatment. To supplement the NHI, Health
Subsystems (for both private and public sectors) were also put in place to for
certain professions, where employee and employer contributions are mandated in
exchange for access to outpatient coverage, which serves as a supplement to NHI
coverage. Furthermore, spending is
managed mostly by regions within the country, of which there are 5 in Portugal,
all of which ultimately report to the Ministry of Health. Additionally, the NHI provides care for
vulnerable populations similar to those populations the U.S. system provides
for, in addition to a few other groups (e.g. those caring for the disabled,
pregnant women, etc.) Under the NHI,
vulnerable populations are exempt from all co-pays, so medical care is
essentially free for them. The NHI also
provides access pharmaceuticals to those with chronic disease, free of charge. The U.S. system, on the other hand generally
demands a small contribution of some kind from the patient, regardless of
chronic illness or disability. Unfortunately,
the hesitancy of the Portuguese government to place restrictions on spending
and increase co-pays and contributions from individuals that utilize the system
has demanded the government to reform this system, and so Voluntary Health
Insurance (VHI) came into existence, which is the equivalent of the private
insurance/payor system in the U.S.
Individuals can elect to pay for certain plans of their choosing, and
pay premiums and co-pays accordingly.
With the advent of VHI, private hospitals and private practices have
sprung into existence. Physicians, once
only limited to the salary given to them by the government through public hospitals
and physician practices, are now able to maximize their salaries by utilizing
the private payer system and can generate added revenue by submitting claims
for direct reimbursement, much like they do in the U.S. While Portugal spends much less than the U.S.
on healthcare (only 10.2% of the GDP and $2,080 per capita annually as opposed
to 15.2% and $6,040 per capita annually according to 2006 WHO statistics), the
system of healthcare in Portugal is gradually moving toward a private payer
system to meet the financial demands of the services that are being provided to
its population at virtually little to no cost.
Each system
is suffering from the financial burden of healthcare and providing access to
its population. While the U.S. struggles
with allowing the government to play a larger role in regulating the business
of healthcare to relieve the population from its ever-increasing costs of care
and limited access, Portugal struggles with reforms aimed at increasing the
financial burden of residents to pay for
the cost of care. Portugal is a
much poorer country than the U.S., evidenced by the GNP figures below:
Portugal’s GNP in 2006 was $19,960 whereas the U.S. GNP in 2006 was $44,070. Interestingly, the U.S and Portugal spend
nearly the same with respect to Social Security expenditure on health care
annually (Portugal spends 1.1% of its government expenditure while the U.S.
spends 0.8%). One of the reasons for
this could be the fact that Portugal has
managed to contain the cost of care per capita with government regulatory
efforts, whereas the U.S., with its free market economy and
technological advancements, have managed to allow for excessive expenditures in
healthcare spending. With increased
U.S. healthcare spending, one would argue that perhaps increased spending
allows for better research, innovative medical technology development, and thus
better quality care that in other countries that spend less per capita.
Unfortunately, while we may have new and innovative technology, the quality of
care patients receive in the States is not necessarily better. Infant mortality, for example, is more than 30
times higher in the U.S. than in Portugal and the under-5 mortality rate is
double in the U.S. than it is in Portugal according the statistics from the WHO
in 2006. Clearly, neither system is
perfect, each with its advantages and disadvantages. Hopefully through reform, government
officials and business executives will come together to create a compromise
that will benefit the greater good.
Whether or not we will see this in our generation or in generations to
come remains a much larger question.
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